Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE): a physiological method of increasing apnoea time in patients with difficult airways

A Patel, S A R Nouraei, A Patel, S A R Nouraei

Abstract

Emergency and difficult tracheal intubations are hazardous undertakings where successive laryngoscopy-hypoxaemia-re-oxygenation cycles can escalate to airway loss and the 'can't intubate, can't ventilate' scenario. Between 2013 and 2014, we extended the apnoea times of 25 patients with difficult airways who were undergoing general anaesthesia for hypopharyngeal or laryngotracheal surgery. This was achieved through continuous delivery of transnasal high-flow humidified oxygen, initially to provide pre-oxygenation, and continuing as post-oxygenation during intravenous induction of anaesthesia and neuromuscular blockade until a definitive airway was secured. Apnoea time commenced at administration of neuromuscular blockade and ended with commencement of jet ventilation, positive-pressure ventilation or recommencement of spontaneous ventilation. During this time, upper airway patency was maintained with jaw-thrust. Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE) was used in 15 males and 10 females. Mean (SD [range]) age at treatment was 49 (15 [25-81]) years. The median (IQR [range]) Mallampati grade was 3 (2-3 [2-4]) and direct laryngoscopy grade was 3 (3-3 [2-4]). There were 12 obese patients and nine patients were stridulous. The median (IQR [range]) apnoea time was 14 (9-19 [5-65]) min. No patient experienced arterial desaturation < 90%. Mean (SD [range]) post-apnoea end-tidal (and in four patients, arterial) carbon dioxide level was 7.8 (2.4 [4.9-15.3]) kPa. The rate of increase in end-tidal carbon dioxide was 0.15 kPa.min(-1) . We conclude that THRIVE combines the benefits of 'classical' apnoeic oxygenation with continuous positive airway pressure and gaseous exchange through flow-dependent deadspace flushing. It has the potential to transform the practice of anaesthesia by changing the nature of securing a definitive airway in emergency and difficult intubations from a pressured stop-start process to a smooth and unhurried undertaking.

© 2014 The Authors Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland.

Figures

Figure 1
Figure 1
The OptiFlow high-flow humidified oxygen delivery system. The oxygen humidification unit (a) receives oxygen from a standard oxygen regulator and delivers humidified oxygen to a custom-built transnasal oxygen cannula (b and c) like a standard nasal oxygen cannula (d).
Figure 2
Figure 2
The relationship between apnoea time and oxygen saturation levels (n = 25). The line represents linear regression with r = 0.136 and p = 0.51.
Figure 3
Figure 3
The relationship between apnoea time and end-tidal (and in four patients, arterial) carbon dioxide levels (n = 24). The line represents linear regression with r = 0.82 and p 2 = (5.2 ± 0.5) + (0.15 ± 0.02) × apnoea time.
Figure 4
Figure 4
Rate of rise of carbon dioxide levels under different apnoea conditions undertaken within the study referred to: (a) airway obstruction; (b) classical apnoeic oxygenation; (c) low-flow intra-tracheal cannula and (d) high-flow intratracheal cannula.

References

    1. Griesdale DEG, Bosma TL, Kurth T, Isac G, Chittock DR. Complications of endotracheal intubation in the critically ill. Intensive Care Medicine. 2008;34:1835–42.
    1. Schulz CM, Endsley MR, Kochs EF, Gelb AW, Wagner KJ. Situation awareness in anesthesia: concept and research. Anesthesiology. 2013;118:729–42.
    1. Cook TM, Woodall N, Frerk C. Major Complications of Airway Management in the United Kingdom: Report and Findings 4th National Audit of the Royal College of Anaesthetists and the Difficult Airway Society. London: National Patient Safety Agency; 2011.
    1. Mort TC. The incidence and risk factors for cardiac arrest during emergency tracheal intubation: a justification for incorporating the ASA Guidelines in the remote location. Journal of Clinical Anesthesia. 2004;16:508–16.
    1. Baraka AS, Taha SK, Aouad MT, El-Khatib MF, Kawkabani NI. Preoxygenation: comparison of maximal breathing and tidal volume breathing techniques. Anesthesiology. 1999;91:612–6.
    1. Weingart SD, Levitan RM. Preoxygenation and prevention of desaturation during emergency airway management. Annals of Emergency Medicine. 2012;59:165–75.
    1. Dixon BJ, Dixon JB, Carden JR, et al. Preoxygenation is more effective in the 25 degrees head-up position than in the supine position in severely obese patients: a randomized controlled study. Anesthesiology. 2005;102:1110–5.
    1. Baillard C, Fosse JP, Sebbane M, et al. Noninvasive ventilation improves preoxygenation before intubation of hypoxic patients. American Journal of Respiratory and Critical Care Medicine. 2006;174:171–7.
    1. Bartlett RG, Jr, Brubach HF, Specht H. Demonstration of aventilatory mass flow during ventilation and apnea in man. Journal of Applied Physiolology. 1959;14:97–101.
    1. Volhard F. Uber kunstliche Atmung durch Ventilation der Trachea und eine einfache Vorrichtung zur hytmischen kunstlichen Atmung. München Medizinische Wochenschrift. 1908;55:209–11.
    1. Draper WB, Whitehead RW, Spencer JN. Studies on diffusion respiration. III. Alveolar gases and venous blood pH of dogs during diffusion respiration. Anesthesiology. 1947;8:524–33.
    1. Holmdahl MH. Pulmonary uptake of oxygen, acid-base metabolism, and circulation during prolonged apnoea. Acta Chirurgica Scandinavica Supplementum. 1956;212:1–128.
    1. Frumin MJ, Epstein RM, Cohen G. Apneic oxygenation in man. Anesthesiology. 1959;20:789–98.
    1. Weitzner SW, King BD, Ikezono E. The rate of arterial oxygen desaturation during apnea in humans. Anesthesiology. 1959;20:624–7.
    1. Eger EI, Severinghaus JW. The rate of rise of PaCO2 in the apneic anesthetized patient. Anesthesiology. 1961;22:419–25.
    1. Fraioli RL, Sheffer LA, Steffenson JL. Pulmonary and cardiovascular effects of apneic oxygenation in man. Anesthesiology. 1973;39:588–96.
    1. Teller LE, Alexander CM, Frumin MJ, Gross JB. Pharyngeal insufflation of oxygen prevents arterial desaturation during apnea. Anesthesiology. 1988;69:980–2.
    1. Hall WH, Ramachandran R, Narayan S, Jani AB, Vijayakumar S. An electronic application for rapidly calculating Charlson comorbidity score. BMC Cancer. 2004;4:94.
    1. Samsoon GL, Young JR. Difficult tracheal intubation: a retrospective study. Anaesthesia. 1987;42:487–90.
    1. Cormack RS, Lehane J. Difficult tracheal intubation in obstetrics. Anaesthesia. 1984;39:1105–11.
    1. Jaber S, Amraoui J, Lefrant J-Y, et al. Clinical practice and risk factors for immediate complications of endotracheal intubation in the intensive care unit: A prospective, multiple-center study. Critical Care Medicine. 2006;34:2355–61.
    1. Gertler MM, Hoff HE, Humm DG. Acid tolerance of the dog heart. American Journal of Physiology. 1946;146:478–86.
    1. Parke RL, McGuinness SP, Eccleston M. A preliminary randomized controlled trial to assess effectiveness of nasal high-flow oxygen in intensive care patients. Respiratory Care. 2011;56:265–70.
    1. Lenglet H, Sztrymf B, Leroy C, Brun P, Dreyfuss D, Ricard J-D. Humidified high flow nasal oxygen during respiratory failure in the emergency department: a feasibility and efficacy study. Respiratory Care. 2012;57:1873–8.
    1. Roca O, Riera J, Torres F, Masclans JR. High-flow oxygen therapy in acute respiratory failure. Respiratory Care. 2010;55:408–13.
    1. Millar J, Lutton S, O'Connor P. The use of high-flow nasal oxygen therapy in the management of hypercarbic respiratory failure. Therapeutic Advances in Respiratory Disease. 2014;8:63–4.
    1. Rello J, Perez M, Roca O, et al. High-flow nasal therapy in adults with severe acute respiratory infection: a cohort study in patients with 2009 influenza A/H1N1v. Journal of Critical Care. 2012;27:434–9.
    1. Kugelman A, Riskin A, Said W, Shoris I, Mor F, Bader D. A randomized pilot study comparing heated humidified high-flow nasal cannulae with NIPPV for RDS. Pediatric Pulmonology. 2014 Mar 12; doi: .
    1. Beggs S, Wong ZH, Kaul S, Ogden KJ, Walters JA. High-flow nasal cannula therapy for infants with bronchiolitis. Cochrane Database of Systematic Reviews. 2014;1:CD009609.
    1. Futier E, Paugam-Burtz C, Constantin JM, Pereira B, Jaber S. The OPERA trial – comparison of early nasal high flow oxygen therapy with standard care for prevention of postoperative hypoxemia after abdominal surgery: study protocol for a multicenter randomized controlled trial. Trials. 2013;14:341.
    1. Roca O, Perez-Teran P, Masclans JR, et al. Patients with New York Heart Association class III heart failure may benefit with high flow nasal cannula supportive therapy: high flow nasal cannula in heart failure. Journal of Critical Care. 2013;28:741–6.
    1. Montanes RG, Messika J, Bertrand F, et al. Interest in High Flow Oxygen Therapy for Improving Oxygenation Pre- and Per- Intubation in the ICU 3rd Paris International Conference on Intensive Care (SRLF & ISICEM) Paris: The French Society of Intensive Care; 2013.
    1. Draper WB, Whitehead RW. Diffusion respiration in the dog anesthetized with pentothal sodium. Anesthesiology. 1944;5:262–73.
    1. Busse EW, Parry TM, Goldensohn ES, Whitehead RW, Draper WB. Alteration of cerebral function in man produced by diffusion respiration and prolonged inhalation of carbon dioxide. Diseases of the Nervous System. 1952;13:35–41.
    1. Sims JL, Morris LE, Orth OS, Waters RM. The influence of oxygen and carbon dioxide levels during anesthesia upon postsurgical hepatic damage. Journal of Laboratory and Clinical Medicine. 1951;38:388–96.
    1. Joels N, Samueloff M. Metabolic acidosis in diffusion respiration. Journal of Physiology. 1956;133:347–59.
    1. Mitchell JH, Wildenthal K, Johnson RL. The effects of acid-base disturbances on cardiovascular and respiratory function. Kidney International. 1972;1:375–89.
    1. Stock MC, Schisler JQ, McSweeney TD. The PaCO2 rate of rise in anesthetized patients with airway obstruction. Journal of Clinical Anesthesia. 1989;1:328–32.
    1. Pandit JJ, Duncan T, Robbins PA. Total oxygen uptake with two maximal breathing techniques and the tidal volume breathing technique. Anesthesiology. 2003;99:841–6.
    1. Meltzer SJ, Auer J. Continuous respiration without respiratory movements. Journal of Experimental Medicine. 1909;11:622–5.
    1. Ritchie JE, Williams AB, Gerard C, Hockey H. Evaluation of a humidified nasal high-flow oxygen system, using oxygraphy, capnography and measurement of upper airway pressures. Anaesthesia and Intensive Care. 2011;39:1103–10.
    1. Tokics L, Hedenstierna G, Strandberg A, Brismar B, Lundquist H. Lung collapse and gas exchange during general anesthesia: effects of spontaneous breathing, muscle paralysis, and positive end-expiratory pressure. Anesthesiology. 1987;66:157–67.
    1. Duncan SR, Mihm FG, Guilleminault C, Raffin TA. Nasal continuous positive airway pressure in atelectasis. Chest. 1987;92:621–4.
    1. Engström J, Hedenstierna G, Larsson A. Pharyngeal oxygen administration increases the time to serious desaturation at intubation in acute lung injury: an experimental study. Critical Care. 2010;14:R93.
    1. Rudolf B, Hohenhorst W. Use of Apneic Oxygenation for the Performance of Pan-endoscopy. Otolaryngolology – Head and Neck Surgergy. 2013;149:235–9.
    1. Watson RJ, Szarko R, Mackenzie CF, Sequeira AJ, Barnas GM. Continuous endobronchial insufflation during internal mammary artery harvest. Anesthesia and Analgesia. 1992;75:219–25.

Source: PubMed

Sponsorer och medarbetare

Medicinska tillstånd

Läkemedelsinterventioner

3
Prenumerera